Natural Course of Inoperable Esophageal Cancer Treated With Metallic Expandable Stents: Quality of Life and Cost-Effectiveness Analysis

Dimitrios Xinopoulos; Dimitrios Dimitroulopoulos; Ioanna Moschandrea; Panagiotis Skordilis; Athanassios Bazinis; Marios Kontis; Ioannis Paraskevas; Elias Kouroumalis; Emmanuel Paraskevas

Disclosures

J Gastroenterol Hepatol. 2004;19(12) 

In This Article

Abstract and Introduction

Background and Aim: The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with self-expanding metallic endoprostheses in the management of malignant esophageal obstruction or stenosis and the cost-effectiveness of the method in patients suffering from primary esophageal carcinoma. All patients with inoperable esophageal cancers treated with either laser palliation or endoprosthesis insertion were studied retrospectively.
Method: Between May 1997 and December 2002 obstruction of the esophagus was diagnosed in 78 patients (52 male, 26 female, age range 53–102 years, mean 72.3 years). The etiology of obstruction was squamous cell carcinoma (n = 42) and adenocarcinoma of the esophagus (n = 36). The site of obstruction was in the upper (n = 1), in the middle (n = 38) and in the lower esophagus (n = 39). In 16 cases the gastroesophageal junction was also involved. Four patients had broncho-esophageal fistulas. In all cases the tumor was considered non-resectable. A total of 89 Ultraflex metal stents were introduced endoscopically. In 46 patients dilation with Savary dilators prior to stent placement was required.
Results: Stents were placed successfully in all patients. After 48 h, all patients were able to tolerate solid or semisolid food. During the follow-up period eight patients developed dysphagia due to food impaction (treated successfully endoscopically). Eleven patients presented with recurrent dysphagia 4–16 weeks after stenting due to tumor overgrowth and were treated with placement of a second stent. The median survival time was 18 weeks. There was no survival difference between squamous cell and esophageal adenocarcinoma. A cost-effective analysis was performed, comparing esophageal stenting with laser therapy. The mean survival and the cost were similar. A small difference of 2156 was noted (23.103 and 22.947 for each group of patients, respectively). A significant improvement in quality of life was noted in patients that underwent stenting (96% and 75%vs 71% and 57% for the first 2 months).
Conclusion: Placement of self-expanding metal stents is a safe and cost effective treatment modality that improve the quality of life, as compared with other palliative techniques, for patients with inoperable malignant esophageal obstructions. In cases of expansion of the mass a second stent can be used; however, the overall survival of these patients, is poor.

Esophageal obstruction of any cause and endoluminal malignancies of external pressure from adjacent neoplasias, is debilitating. The most distressing symptom for the vast majority of patients with malignant obstructions of the esophagus is dysphagia. The relief of this condition associated with nutritional and psychosocial support must be the primary goal of palliation.

More than 50% of patients with neoplastic disease of the esophagus or esophagogastric junction at the time of diagnosis, are not suitable for curative surgical resection because of advanced local disease, extensive distant metastases, or both. 1–3 Therefore, these patients are palliatively treated, either by surgery, radiotherapy, chemotherapy or endoscopic therapy.

Some investigators consider esophageal resection and reconstruction with esophagogastrostomy the best method of palliation.[4,5] With a mortality rate of 13–22% and a high complication rate of 36–71%; however, surgery is an unsuitable palliative treatment for patients who have a median survival rate of 6 months.[2,6,7] Chemotherapy is completely ineffective for palliation[8] and external radiotherapy can cause a temporary increase of dysphagia and carries a short-lasting effect.[9,10]

Endoscopic options currently available include esophageal dilation,[11] bipolar electrocoagulation,[12] injection of sclerosing agents,[13] photodynamic therapy[14] and brachytherapy;[15] however, none provide adequate palliation in a single treatment session with a low complication rate.

It is clear that the palliation for esophageal malignant obstructions should be based on the safety of the procedure, restoration of swallowing, diminution of frequency and duration of hospital stay, all at a reasonable cost.[4]

On this basis, the most commonly used palliative endoscopic modalities today are laser ablation of the tumor and stenting.[16,17]

Laser therapy restores the patency of the esophageal lumen to near normal with a complication rate ranging between 1 and 7%,[18,19] but needs to be frequently repeated. In contrast, stenting provides a satisfactory and long-lasting palliation in one session.

Two types of esophageal endoprostheses are commercially available:

  1. Rigid plastic stents (e.g. Atkinson, Celestine). Their placement requires the presence of an anesthesiologist and are associated with an overall complication rate of 36% and high mortality rates.[7,20] The quality of swallowing is often poor and many patients can eat only semisolid food.

  2. Self-expandable metallic endoprostheses are effective in the palliation of symptomatic esophageal malignant strictures.[3,21,22] Due to their large diameter (18–25 mm), relief of dysphagia is immediate and usually permanent once the stent is in place. Despite their higher cost, the metal stents are cost-effective with a shorter hospital stay and result in fewer fatal complications than plastic tubes.[3] They can usually be inserted under light sedation and local anesthesia, do not require excessive dilation and expand progressively, adapting to the force of the stenosis.

The aim of the present study was to assess the efficacy and safety of these stents, to study the natural course of esophageal malignancies after their placement and to compare the method as to cost effectiveness and quality of life with endoscopic laser therapy.

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